Portos, airports and borders

NATIONAL AGENCY OF SANITARY

SURVEILLANCE

PORTOS, AIRPORTS AND BORDERS

	Free Pratique Derating
	2. Identification of the Direct Responsible or Legal Representative for the Embarkation
	2.1 Master name:
2.2 Seaman’s Book and or passport:	2.3 Nr:
2.4 Address:	2.4.1 NR:
2.4.2 Village:	2.4.3 City:
2.5 Vsl-s telephone: ()	2.5.1 Fax: ()	E-mail:
	3. Snip’s particulars
	3.1 Name:	3.2 Flag
3.3 IMO NR:	3.4 NRT	3.5 GRT
3.6 Type of Navigation:	3.7 Activity or Service: NOT TO BE FILLED IN	3.8 Type of Embarkation
3.9 Max capacity for Crew on board as per safe manning cert.:	3.10 Max capacity for Passengers as per safe manning cert.
3.11 Nr. of Tanks for Ballast:	3.12 Is there Ballast water management plan onboard? YES NO 3.13 Was it implemented? YES NO 3.14 Is there ballast water IMO guidelines? YES NO
	4 Information on the trip
	4.1 Arrival date:	4.2 Estimated arrival time (E.T.A):	4.3 Estimated departure dale – ETD:
4.4 Porto of Destination	4.4.1 Country
4.5 Actual nr of Crew members:	4.6 Actual nr of Passengers:
4.7 Call ports in decreasing chronological order, during the last thirty days stating name of the port, country and departure dates each one.
4.7.1 type of Traffic: NOT TO BE FILLIED IN	4.7.2 type of Displacement NOT TO BE FILLIED IN
4.8 MASTER’S NAME:	4.8.1 Nationality:
4.9 Death occurrence on board? YES NO 4.l0 Was there banal in high sea? YES NO 4.11 occurrence of disease on board? YES NO 4.11.1 with signs of fewer and or hemorrhage? YES NO 4.11.2 with jaundice signs? YES NO 4.11.3 with diarrhea signs? YES NO 4.11.4 with signs of neurological dysfunctions? YES NO 4.11.5 with cough signs or breathing difficulty? YES NO 4.l2 accident occurrence on board? YES NO 4.13 occurrence of mortality of rodents on board? YES NO 4.13.1 If affirmative, specify which compartment(s).
4.14 Expiration date for De-rating Certificate or Exemption for De-ratting.
4.14.1 Place where it was issued:
4.15 occurrence of medicine(s) consumption during the voyage: YES NO
4.15.1 if affirmative. specify the name of the medicine(s):

Uis	5. To continue fillinfl»n this picture when requiring Certificate of Free Pratique
	5.1 produce potable water on board? YES NO
5.2 Port where the last potable water supplied:
5.3 Is there system of treatment of potable water?		YES		NO
5.4 maximum capacity for storing potable water: liter(s) m^3
5.5 is there ballast water on board? YES NO
5.5.1 place of the last reception: Latitude: Longitude: Port:
5.5.2 Was exchanged the ballast water?		YES		NO
5.5.3 place where occurred exchanging: Latitude: Longitude:
5.5.4 place of the last de-ballast: Latitude: Longitude: Port:
5.5.5 Are you deballasting at this port?		YES NO		NO
5.6 is there retention tank of sewage?		YES NO		NO
5.6.1 Maximum capacity for storing sewage: m^3
5.6.2 retention autonomy, in function of nr. of people (crew/passenger)on board: days
5.7 transport dangerous cargo?		YES		NO
5.8 occurrence on board of cargo desinsectization / fumigation. YES. NO
5.8.1 if affirmative, specify the product used and date:
5.9 tax of Sanitary Fiscalization for Certificate of Free Practice with exemption without exemption	5.9.1 date of payment:
5.9.2 Port where it was paid:
	6. To fill be filled in this picture only when it is requiring De-ratting Certificate or Exemption for de-ratting
	6.1 type of Certificate. National International
6.2 tax of Sanitary Fiscalization: with exemption without exemption	6.2.1 date from the deposit:
6.2.2 code of the Port Position
	7. Term of Responsibility: I assume the truthfulness of the information above rendered and undertake to fulfill all the other established demands in the federal sanitary legislation pemnent and the responsibility for the payment of any tax of Sanitary Fiscalization and fine related to the sanitary infraction due to the entrance, permanence, operation and departure of the vessel from the port of Sanitary Control. .....-.„-.-,,,,...„,..,.-.,,,., -...,1
	8. Identification of the Requester or his/her Legal Representative;
8.1 place:	8.2 date:	8.3 Passport
8.4 name:	8.5 signature:

ITEM 5.9 / 5.9.1 / 5.9.2 + WHOLE ITEM 06, 07 & 08 ARE NOT TO BE FILLED IN.

Дата добавления: 2015-10-23